Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique?

PURPOSE: The use of buccal mucosa graft onlay urethroplasty represents the most widespread method of bulbar urethral stricture repair. The graft may be placed on the ventral or dorsal urethral surface according to surgeon experience and preference. We investigated whether the results are affected by the surgical technique by comparing the outcome of 3 types of bulbar urethroplasty using buccal mucosa graft. MATERIAL AND METHODS: We repaired 50 bulbar urethral strictures with buccal mucosa grafts from 1997 to 2002. Mean patient age was 42 years. The etiology of stricture was ischemia in 12 cases, trauma in 6, instrumentation in 4 and unknown in 28. Patients with lichen sclerosus, failed hypospadias or urethroplasty and stricture extending into the penile urethra were not included. A total of 47 patients (94%) had undergone previous urethrotomy or dilation. The buccal mucosa graft was always harvested from the cheek using a 2 team approach. Mean graft length was 4.2 cm. The graft was placed on the ventral, dorsal and lateral bulbar urethral surface in 17, 27 and 6 cases, respectively. Clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 42 months (range 12 to 76). RESULTS: Of 50 cases 42 (84%) were successful and 8 (16%) failed. The 17 ventral grafts provided success in 14 cases (83%) and failure in 3 (17%). The 27 dorsal grafts provided success in 23 cases (85%) and failure in 4 (15%). The 6 lateral grafts provided success in 5 cases (83%) and failure in 1 (17%). No surgical complications were observed. Failures involved the anastomotic site (distal in 2 and proximal in 3) and the whole grafted area in 3 cases. They were treated with urethrotomy in 5 cases and 2-stage urethroplasty in 3. CONCLUSIONS: In our experience the placement of buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success rates (83% to 85%) and the outcome was not affected by the surgical technique. Moreover, stricture recurrence was uniformly distributed in all patients.     

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures

PURPOSE: We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures. MATERIALS AND METHODS: Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra. RESULTS: At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group. CONCLUSIONS: Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.     

Bulbar urethral stricture repair with buccal mucosa graft urethroplasty

OBJECTIVES: Evaluation of the use of buccal mucosa graft as single-stage urethral reconstruction in an adult population with a stenosis of the bulbar urethra. METHODS: In our Department between April 1996 and February 1999, 20 patients with bulbar urethra stenosis underwent single-stage urethroplasty using a buccal mucosa graft. Mean age of patients was 52 years (range 14-70). The etiology of urethral stricture was inflammation (4 cases), iatrogenic (5 cases) and idiopathic (11 cases). A ventral onlay patch (mean length 3.6 cm, range 2.5-5) was employed in all cases. RESULTS: During the follow-up (median 13 months, range 6-28) the overall success rate was 80%. The success rate was 75% for inflammatory strictures, 80% for iatrogenic strictures and 81% for strictures of unknown etiology. CONCLUSIONS: Although longer follow-up is needed, free graft urethroplasty with buccal mucosa graft represents a simple surgical option which has produced encouraging results. This is probably due to the quality of the tissue employed which at present seems to represent the first-choice solution in selected cases.     

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Male anterior urethral stricture is scarring of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen, decreasing the urinary stream. Its surgical management is a challenging problem, and has changed dramatically in the past several decades. Open surgical repair using grafts or flaps, called substitution urethroplasty, has become the gold standard procedure for anterior urethral strictures that are not amenable to excision and primary anastomosis. Oral mucosa harvested from the inner cheek (buccal mucosa) is an ideal material, and is most commonly used for substitution urethroplasty, and lingual mucosa harvested from the underside of the tongue has recently emerged as an alternative material with equivalent outcome. Onlay augmentation of oral mucosa graft on the ventral side (ventral onlay) or dorsal side (dorsal onlay, Barbagli procedure) has been widely used for bulbar urethral stricture with comparable success rates. In bulbar urethral strictures containing obliterative or nearly obliterative segments, either a two‐sided dorsal plus ventral onlay (Palminteri technique) or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) are the procedures of choice. Most penile urethral strictures can be repaired in a one‐stage procedure either by dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one‐sided urethral dissection (Kulkarni technique); however, staged urethroplasty remains the procedure of choice for complex strictures, including strictures associated with genital lichen sclerosus or failed hypospadias. This article presents an overview of substitution urethroplasty using oral mucosa graft, and reviews current topics.     

Buccal mucosal urethroplasty: a versatile technique for all urethral segments

OBJECTIVE: To present our experience with buccal mucosa urethroplasty for substitution of all segments of the anterior urethra, as the buccal mucosal graft (BMG) has emerged as the tissue of choice for single-stage reconstruction of bulbar urethral strictures, but its use for reconstructing meatal, pendulous and pan-urethral strictures has not been widely reported. PATIENTS AND METHODS: Between January 1998 and October 2003, 92 patients had a BMG substitution urethroplasty at our institution; 75 had a single-stage dorsal onlay BMG urethroplasty (bulbar 41, pendulous 16 and pan-urethral 18; six combined penile skin flap and BMG) and 17 (pendulous five, pan-urethral 10, bulbar two) a two-stage urethroplasty. Recurrence rates, complications and cosmetic outcomes were analysed retrospectively. RESULTS: Over a median (range) follow-up of 34 (8-72) months, 66 (88%) patients with a one-stage reconstruction (14/16 pendulous; 37/41, 90%, bulbar; 15/16 pan-urethral) remained stricture-free. The mean (range) time to recurrence was 9.4 (3-17) months. Of the nine recurrent strictures, six were managed by one-stage optical urethrotomy and three required a repeat urethroplasty. In patients who had a staged procedure, after a mean follow-up of 24.2 (9-56) months, one had complete graft loss, requiring re-grafting, five required stomal revision after stage 1, and only two (12%) developed a recurrent stricture after the two-stage urethroplasty. CONCLUSION: A one-stage dorsal onlay BMG urethroplasty provides excellent results for strictures involving any segment of the anterior urethra. The BMG appears to be the most versatile urethral substitute, as it can be successfully used for both one- and two-stage reconstruction of the entire anterior urethra.     

Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction

PURPOSE: We investigate whether the short-term success rate (greater than 90%) of buccal mucosa free grafts in the bulbar urethra is sustained in the long term. MATERIALS AND METHODS: In 60 patients a ventrally placed buccal mucosa graft was used for repair of bulbar urethral strictures. Of these patients 49 had undergone previous attempt at repair (urethroplasty in 4, internal urethrotomy in 45). Mean graft length was 4.8 cm. In 9 patients a distal penile fasciocutaneous flap was also used for repair of concomitant penile urethral stricture. In 8 of the 9 patients the buccal mucosa graft was combined with end-to-end urethroplasty and 2 buccal mucosa grafts were used in tandem in 1. Followup was at least 1 year in all cases (mean 47 months, range 12 to 107). Failure was defined as an obstructive voiding pattern with radiographic or cystoscopic evidence of recurrent stricture. RESULTS: Bulbar stricture repair was successful in 54 patients (90%) and 4 of the remaining 6 responded to 1 internal urethrotomy for a long-term success rate of 97%. Preoperative clinical characteristics were not significantly different between those who experienced success or failure. CONCLUSIONS: Long-term outcome analysis of ventrally placed buccal mucosa onlay grafts for bulbar urethral strictures demonstrates a durable success rate of 90%. This rate can be improved (97%) with the judicious use of internal urethrotomy.     

Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture

PURPOSE: We report the early outcome of dorsal full-thickness penile skin grafts in the repair of bulbar urethral stricture. MATERIALS AND METHODS: During 27 months 29 men with a mean age of 43 years (range 10 to 81) underwent dorsal onlay graft urethroplasty. Followup included retrograde urethrogram at 3 weeks, 3 months and 12 to 18 months, and thereafter when needed. Urinary flow was recorded as subjectively reported by the patients. RESULTS: The technique was used only for bulbar urethral strictures. A total of 23 patients (79%) had undergone previous direct vision urethrotomy and/or open surgery. Dorsal onlay graft urethroplasty was used alone in 12 patients (41%), and was performed with partial stricture excision and ventral strip anastomosis in 13 (45%). In another 4 patients (14%) the procedure was combined with an Orandi flap because the stricture extended significantly into the penile urethra. Penile skin grafts were used in 27 patients (93%), whereas buccal mucosa was harvested in 2. Mean graft length was 6 cm. (range 3 to 9), and width ranged between 1.5 and 3 cm. Outcome was favorable in 28 patients (97%) for a median followup of 19 months (range 10 to 37). One patient had symptomatic proximal stricture recurrence and 3 had radiographic evidence of caliber decrease of the repair but with no impact on urinary flow. CONCLUSIONS: Dorsal onlay graft urethroplasty is a versatile procedure which may be combined with stricture excision and ventral strip anastomosis or an Orandi flap. Conceptually the technique offers the advantages of spread fixation of the graft on a fixed well vascularized surface, which may improve graft neovascularization, reduce graft shrinkage and avoid sacculation. Although the early outcome is promising, dorsal onlay graft urethroplasty has yet to stand the test of time.     

Optimal management of the 3- to 6-centimeter anterior urethral stricture

The optimal management of anterior urethral stricture that does not respond to an endoscopic urethrotomy or is found to be unsuitable for excision and anastomotic repair remains controversial. Genital skin island onlay flaps or buccal mucosal grafts are presently the most dependable single stage procedures used for strictures more than 3 cm in length. Nonhirsute penile island fasciocutaneous flaps constitute the most durable substitution technique for pendulous stricture disease, with long-term studies reporting 90% to 96% success. The complex proximal bulb and bulbomenbraneous stricture with a compromised proximal fibrous avascular bed is ideally managed with either a penile or scrotal island flap or some combination of partial urethral excision with a dorsally placed genital skin island. The buccal mucosal onlay graft is a promising addition to this reconstructive paradigm, and early outcomes have been favorable. The graft is presently used for bulbar strictures, avoiding the transsphincteric on pendulous location, or a compromised recipient bed. The present standard of care for proximal bulb strictures is wide bulbospongiosal mobilization, partial urethral excision, a floor strip anastomosis, and placement of an augmenting flap on the graft in a dorsal location.     

DORSAL ONLAY GRAFT URETHROPLASTY USING PENILE SKIN OR BUCCAL MUCOSA IN ADULT BULBOURETHRAL STRICTURES

Purpose

Preputial skin graft is used routinely for urethral reconstruction in patients with stricture disease. Alternative donor sites include extrapenile skin, bladder mucosa and buccal mucosa. Recently buccal mucosa graft has been suggested when local epithelial tissue is not available. We describe our experience with 37 patients undergoing 1-stage correction of bulbar urethral stricture using a penile skin (31) or buccal mucosa (6) graft.

Materials and Methods

In 37 patients with bulbar urethral strictures a nontubularized dorsal onlay graft was used for urethral reconstruction. A preputial skin graft was used in 31 patients and a buccal mucosa graft in 6 with a paucity of local skin. Buccal mucosa graft length ranged from 2.5 to 5 cm. (average 4) and preputial skin graft was 2.5 to 12 cm. long (average 4.7). A dorsal approach to the urethral lumen was used in all patients who underwent onlay graft urethroplasty.

Results

Mean followup was 21.5 months for all 37 patients, 23 months for 31 treated with preputial skin graft and 13.5 months for 6 treated with buccal mucosa graft. The clinical outcomes were considered a failure anytime postoperative instrumentation was needed, including dilatation. In the series 34 cases (92%) were classified as a success and 3 (8%) as failure.

Conclusions

Onlay graft urethroplasty provided excellent results in 92% of adults with bulbourethral stricture. The dorsal approach to the urethra allowed the use of foreskin or buccal mucosa graft for reconstruction of the adequate urethral lumen.     

A comparison of one-stage procedures for post-traumatic urethral stricture repair

OBJECTIVE: To compare the results and complication rates of various one-stage treatments for repairing a post-traumatic urethral stricture. PATIENTS AND METHODS: The medical records of 153 patients who had a post-traumatic urethral stricture repaired between 1977 and 2003 were evaluated retrospectively, and analysed for the different types of urethral reconstruction. RESULTS: The procedures included direct end-to-end anastomosis in 86 (56%) patients, free dorsal onlay graft urethroplasty using preputial or inguinal skin in 40 (26%), ventral onlay urethroplasty using buccal mucosa in seven (5%) and ventral fasciocutaneous flaps on a vascular pedicle in 20 (13%). At a mean (median, range) follow-up of 75.2 (38, 12-322) months, 121 (79%) patients had no evidence of recurrent stricture, while in 32 men (21%) they were detected at a mean follow-up of 30.47 (1-96) months. Patients having a dorsal onlay urethroplasty had the longest strictures. The re-stricture rate was lowest after a dorsal onlay urethroplasty (5% vs 27% when treated with end-to-end anastomosis, 15% after fasciocutaneous flaps and 57% after a ventral buccal mucosal graft). The surgical technique used had no effect on postoperative incontinence or erectile dysfunction rates. CONCLUSION: In patients with strictures which are too long to be excised and re-anastomosed, tension-free dorsal onlay urethroplasty is better than ventral graft or flap techniques. In patients with short urethral strictures direct end-to-end anastomosis remains an option for the one-stage repair of urethral stricture.     

The vascularized skin island urethroplasty: its role and results in urethral stricture management

We report 11 vascularized island skin flap urethroplasties. Results appear to be excellent when the procedure is used for strictures of the pendulous urethra. Use of vascularized skin flap urethroplasties for the repair of bulbar and membranous strictures has been complicated by pseudodiverticula and stone formation, and in this portion of the urethra the technique probably should be reserved for cases in which local factors mitigate against alternative 1-stage procedures.     

Management of panurethral strictures

IntroductionPan-urethral stricture, involving the penile and bulbar urethra, is a common urological problem on the South Asian subcontinent. It represents a particularly difficult challenge to manage and there is a relative paucity of literature on the subject. In India, Lichen Sclerosus (LS) is the most common cause of pan-urethral stricture, followed by iatrogenic causes.2 stage surgery is not scientific in lichen sclerosus as this is a disease of genital skin. We present our experience of pan-urethral stricture repair using a single-stage, one-sided dissection, dorsal onlay repair with oral mucosa graft.Subjects and methodsWe retrospectively reviewed the records of 318 consecutive men undergoing management of pan-urethral stricture from June 1995 to December 2014. The median age was 44.6 years and the mean stricture length 14 cm. The median follow-up was 59 months. The strictures were approached through a perineal incision, limiting dissection to only one side of the urethra. The penis was invaginated to provide access to the entire length of anterior urethra in a single-stage, and two oral mucosal grafts were dorsally placed.ResultsThe outcome was considered a success if the patient needed no further instrumentation, including dilation or urethrotomy. The overall success rate was 84.90%, with a success rate of 89.39% in primary urethroplasty, and 57.85% in patients who had previous failed urethroplasty. Most recurrent strictures occurred at the proximal end of the graft.ConclusionsRepair of pan-urethral stricture in a single-stage, with one-sided dissection and dorsal onlay of oral mucosa, is a minimally invasive technique that is simple, fast, safe, effective and reproducible in the hand of any surgeon.     

Retrospective outcome analysis of urethroplasties performed for various etiologies in a single South African center

ObjectivesTo compare the results of anastomotic versus augmentation urethroplasty (buccal mucosa graft (BMG) onlay), as well as dorsal versus ventral BMG techniques.MethodsA retrospective audit of 69 patients who underwent urethroplasty at Eersteriver Hospital in Cape Town, South Africa between October 2004 and July 2011 was undertaken. Analysis included stricture etiology, location and length, type of surgery performed as well as complication rates over the follow-up period.ResultsThe predominant stricture etiologies were traumatic and infective causes (55%), with a mean stricture length of 3 cm (0.5–15 cm). Forty two patients had bulbar urethra strictures (61%), with 8 (11%) located in the posterior, and penile & bulbar regions, respectively. The remaining strictures were located in the penile urethra (16%). Surgery performed included bulbar (12) and membranous anastomotic (8) urethroplasty, ventral (13) and dorsal (22) buccal mucosa onlay grafts (BMG), and 2-stage urethroplasty (14). Overall stricture recurrence was seen in 9 patients (13%), including 1 patient (8%) of the anterior end-to-end anastomotic group compared to 2 patients (6%) of the onlay BMG group (p = 0.77). The re-stricture rates were 5% and 8% in the dorsal (1/22) and ventral BMG onlay groups (1/13), respectively (p = 0.72).ConclusionsBoth anastomotic and BMG onlay techniques are safe and effective surgical options. Similar outcomes were demonstrated between ventral and dorsal BMG onlay groups.     

Buccal mucosa urethroplasty in anterior urethral strictures

Buccal mucosal graft can be used for succesfull repair in both pendulous and bulbar strictures. MATERIAL AND METHODS: We present our experience with buccal mucosal graft repair in 8 patients with onlay patch that varies from 4 to 16 cm. in length. Three pendulous, two bulbar and three panurethral strictures were repaired. These patients were observed for 36 to 60 months. RESULTS: No stricture recurrences were observed. Only one patient had lower lip paresthesia for six months.     

Die plastische Rekonstruktion der Harnröhre

There is no technique which can be used in all types and localizations of urethral strictures. Urethral strictures occur in the majority of cases in the bulbar urethra. The success rate of urethroplasty is above 80% and results are much better compared to DVIU. Dorsal onlay shows a significantly better success rate than ventral onlay. If the graft bed has poor vascularization a flap should be used or a staged approach should be considered.     

Urethroplasty for refractory anterior urethral stricture.

PURPOSE: We present our results managing anterior urethral strictures previously treated with urethroplasty and/or urethrotomy. MATERIALS AND METHODS: During a 32-month period 69 males 10 to 76 years old (mean age 36) underwent treatment for anterior urethral stricture, including 32 (46%) and 26 (38%) previously treated with urethroplasty and urethrotomy, respectively. In 11 patients (16%) no previous procedures had been done. Anastomotic and dorsal patch urethroplasty was performed for bulbar stricture in 13 and 14 cases, respectively, while in 4 a penile skin flap was placed for penile stricture and in 38 a 2-stage procedure was done with urethral substitution using buccal mucosa or post-auricular skin grafts. Patients were followed with ascending urethrography at 3 weeks, and 12 and 18 months as well as with uroflowmetry. Symptoms were assessed for 6 months to 4 years. RESULTS: Only 1 stricture recurred in patients treated with anastomotic or patch urethroplasty, or a skin flap. Of the patients scheduled for a 2-stage procedure stage 1 revision was required due to graft scarring or stenosis at the urethrostomy site in 21% and stage 2 revision was required in 23%. Other complications in this series included fistula in 3% of cases, wound infection in 3% and post-void dribbling in 12%. CONCLUSIONS: Overall early results are good in our urethroplasty series in patients with a previously instrumented urethra. Patients should be advised of the possible need for multiple revisions of planned staged procedures. The increased rate of revision in these staged procedures compared with the excellent outcome of 1-stage procedures appears to be inherent in this operation in patients with multiple previous procedures rather than due to surgeon experience.     

One-stage repair of long bulbar urethral strictures using augmented Russell dorsal strip anastomosis: outcome of 234 cases

Objectives

Long bulbar urethral strictures (>2 cm) are not amenable to stricture excision and primary anastomosis procedure, which may result in a short urethra and chordee formation. For such strictures many procedures have been advocated including stricturotomy with subsequent graft or flap onlay, augmented anastomosis, and staged procedures, which is a combination of the Russell graft. We present our 10-yr experience with the augmented Russell procedure using a ventral onlay buccal mucosal patch graft for treatment of long bulbar urethral strictures not amenable to excision and primary anastomosis.

Methods

A total of 234 patients diagnosed by urethrograms as having long bulbar urethral strictures (mean, 4.2 cm) were managed by the augmented Russell urethroplasty. The procedure included excision of most of the diseased segment (mean, 2.8 cm) and anastomosis of a dorsal strip leaving an oval ventral defect. Augmentation was done in all patients using a buccal mucosa patch graft (mean, 4.7 cm).

Results

Mean follow-up was 36 mo. Urethrograms were done at 3 wk and 3 and 6 mo postoperatively and if the patients were symptomatic thereafter. Urethrocystoscopy was performed at 12 and 18 mo. A total of 223 patients completed the follow-up protocol; the overall success rate was 93.7% with 14 (6.3%) patients showing stricture recurrence at different intervals postoperatively. Ten patients in the failure group were successfully managed by single visualized internal urethrotomy (VIU), whereas the other four patients were treated by ventral penile pedicled flap. Postoperative dribbling of urine was noticed by 90 patients (40.4%) and temporary perioral numbness in most patients; no major donor site complications were noted in our series.

Conclusion

The augmented Russell technique is beneficial for long bulbar urethral strictures; 93.7% of the patients were stricture free. In the bulbar region, both ventral and dorsal onlays are applicable with nearly equal success rates. The buccal mucosa patch graft offers excellent material for augmentation.     

口腔内黏膜尿道成形治疗前尿道狭窄10年经验总结

目的 探讨口腔内黏膜尿道成形治疗尿道狭窄的长期效果. 方法 2001年1月至2010年12月,应用口腔内黏膜(颊黏膜和舌黏膜)尿道成形治疗前尿道狭窄255例.尿道狭窄段长度3 ～18 cm,平均6 cm.尿道成形采用保留原尿道板的扩大尿道成形术或埋藏黏膜条背侧替代尿道成形术.对49例尿道狭窄段≥8 cm者采取双侧颊黏膜拼接、颊粘膜与舌黏膜拼接或双侧连续长条舌黏膜尿道成形. 结果 术后随访8 ～120个月,平均37个月.230例患者排尿通畅,尿线粗,最大尿流率为16～51 ml/s,平均26 ml/s.尿道造影显示重建段尿道管腔通畅.总成功率90.2％.25例患者于术后1年内发生并发症,其中尿道再次狭窄17例,尿道皮肤瘘8例.17例尿道再狭窄患者中15例再次行口腔内黏膜尿道成形,2例吻合口狭窄行尿道内切开,术后排尿通畅;8例尿道皮肤瘘均接受尿瘘修补术后治愈. 结论 口腔颊黏膜和舌黏膜均是良好的尿道替代物,舌黏膜取材较颊黏膜更为便利;口腔内多种黏膜的组合移植重建尿道是治疗长段前尿道狭窄( ≥8 cm)的有效方法.     

Changing practice in anterior urethroplasty

OBJECTIVE: To describe our experience of penile urethral repair and reconstruction, cataloguing the change in practice from one-stage flap to two-stage free graft procedures for anterior urethroplasty. PATIENTS AND METHODS: Between January 1992 and December 1996, 79 patients underwent anterior urethroplasty. Of the 45 one-stage bulbar patch urethroplasties, 37 (76%) used buccal mucosal free grafts rather than flaps. Of the 34 penile urethroplasties, 26 (82%) (including all of the circumferential reconstructions) were two-stage procedures. RESULTS: Buccal mucosal free grafts were at least as good as local skin flaps for patch urethroplasty and two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra. CONCLUSIONS: For a patch urethroplasty of an uncomplicated stricture in the bulbar urethra, buccal mucosal free grafts are now the material of choice. For a patch urethroplasty of an uncomplicated stricture in the penile urethra the Orandi procedure remains the 'gold standard'. For a circumferential repair of the urethra, particularly the penile urethra, a two-stage repair using a free graft gives better results than a one-stage repair using a flap.     

New 2-stage buccal mucosal graft urethroplasty.

PURPOSE: Previously buccal mucosal grafts used for repairing adult bulbourethral stricture with the 1-stage dorsal technique has provided a satisfactory outcome in our experience. We present the wider use of buccal mucosal grafts for 2-stage urethroplasty. MATERIALS AND METHODS: A total of 24 men 25 to 60 years old (median age 45) with a complex bulbar stricture underwent 2-stage urethroplasty using a buccal mucosal graft to repair the perineostomy. The primary etiology of stricture was traumatic in 4 cases, inflammatory in 16 and unknown in 4. The 2 x 6 cm. graft was harvested from the inner cheek and sutured to the left margin of the urethral mucosal plate with running 6-zero polyglactin suture. Patients were discharged from the hospital within 3 days with a 14Fr silicone urethral catheter in place. Radiological studies and urethroscopy were done 1 year after closure. RESULTS: A final successful outcome with no recurrent stricture was achieved in 23 of 24 men (92.8%) at a median followup of 18 months (range 13 to 32). In 1 case a urethrocutaneous fistula at the initial radiological assessment closed spontaneously after 14 days of catheterization. No urethral diverticula developed. The mean postoperative peak flow rate is 22 ml. per second (range 18 to 25). CONCLUSIONS: Our new 2-stage buccal mucosal graft urethroplasty may be an excellent technique for complex bulbar urethral stricture disease. Our suggestions may increase usefulness of the 2-stage technique for repairing complex strictures due to the avoidance of classic complications.